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<br />Saint Anthony Village ADA Grievance Form Page 2 <br />When did the discrimination occur? ______________________________ Date: __________________ <br />Describe the acts of discrimination providing the name(s) where possible of the individuals who <br />discriminated (use space on page 3 if necessary): <br /> <br /> <br /> <br />Have efforts been made to resolve this complaint through the internal grievance procedure of the <br />government, organization, or institution? <br />Yes ______ No _____ <br />If yes: what is the status of the grievance? <br /> <br /> <br /> <br />Has the complaint been filed with another bureau of the Department of Justice or any other Federal, State, <br />or local civil rights agency or court? <br />Yes ______ No _____ <br />If yes: <br /> <br />Agency or Court:______________________________________________________________________ <br /> <br />Contact Person: _______________________________________________________________________ <br /> <br />Address: ____________________________________________________________________________ <br /> <br />City, State, and Zip Code: _______________________________________________________________ <br /> <br />Telephone Number: ___________________________________________________________________ <br /> <br />Date Filed: ___________________________________________________________________________ <br /> <br /> <br /> <br /> <br /> <br /> <br />